Prevention of Rhabdomyolysis in Bariatric Surgery
Transcrição
Prevention of Rhabdomyolysis in Bariatric Surgery
Obesity Surgery, 15, 874-879 Review Article Prevention of Rhabdomyolysis in Bariatric Surgery João Eduardo Marques Tavares de Menezes Ettinger, MD1; Paulo Vicente dos Santos Filho2; Euler Azaro, MD, PhD1; Carlos Augusto Bastos Melo, MD1; Edvaldo Fahel, MD, PhD1; Paulo Benigno Pena Batista, MD, PhD2 1 Bariatric Surgery Division and 2Nephrology Division, São Rafael Hospital, and Department of Surgery Escola Bahiana de Medicina, Salvador, Bahia, Brazil Background: Rhabdomyolysis (RML) is a clinical and Introduction biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intraObesity is a complex and multifactorial disease cellular contents from the myocytes into the circulainfluenced by psychological, genetic endocrinetory system. Postoperative RML in bariatric surgery metabolic and ambiental interaction.1,2 Morbid obeoccurs with various non-physiological surgical posisity causes physical, emotional, economic and tions, with prolonged muscle compression. The social problems.3 Currently, >60% of Americans are potential consequences may lead to death. The purDelivered by Ingenta to: unknown pose of this study is to review its pathophysiology overweight, and 12 million people in the USA are 127.0.0.1 and the best ways to prevent RML in bariatric surgery. morbidly obese, defined as a body mass index on: Mon, 20 Jun 2005 15:26:40 Methods: We searched the literature and reviewed (BMI) >40 kg/m2.4,5 In Brazil, the number of morall relevant articles, by searching for the keywords: bidly obese adults and children increases daily and rhabdomyolysis, morbid obesity, prevention and ≈30% of the Brazilian population is overweight.3 bariatric surgery, giving a total of 39 articles. Obesity is a worldwide epidemic, and the obese Results: Prevention may be enhanced by careful have a nearly 12 times higher risk of premature padding on the operative table at all pressure-points. death.6,7 Health-care costs are 44% greater among Changing patient position, both intraoperatively and severely obese patients, representing a public health postoperatively, also reduces RML. A potential new problem in developed and developing countries.4,8 solution to decrease the longer operative time and avoid At present, the only available therapeutic interRML is to perform the bariatric operation in two stages. vention that provides effective long-term weight Another way to limit the duration of surgery in high-risk morbid obesity is bariatric surgery.4,9-13 loss for patients is to alert surgeons not to select super-obese An unusual event that is a potentially fatal comhigh-risk patients early in the learning curve. Conclusion: As RML is an important and potentially plication of bariatric surgery is rhabdomyolysis fatal complication of bariatric surgery, the best way to (RML).14 This clinical and biochemical syndrome avoid it is effective prevention. More research on this caused by skeletal muscle necrosis, results in subject is necessary. extravasation of toxic intracellular contents from the Key words: Rhabdomyolysis, bariatric surgery, morbid obesity, prevention, renal failure Reprint requests to: João Eduardo Marques Tavares de Menezes Ettinger, Av. Princesa Leopoldina, 21, apt. 1304, Graça, Salvador, Bahia, Brazil 40150-080. E-mail: [email protected] or [email protected] 874 Obesity Surgery, 15, 2005 myocytes into the circulatory system.15-20 Postoperative RML in bariatric surgery is an event which occurs with various non-physiological surgical positions and prolonged muscle compression.21 If prevention is not done, or the diagnosis is delayed, and appropriate treatment is not instituted, serious complications and even death can occur. We © FD-Communications Inc. Prevention of Rhabdomyolysis evaluated the best ways to prevent RML in obesity surgery and its pathophysiology. tion between intracellular and extracellular molecules. First is the cell membrane; damage to this essential structure allows intracellular contents to escape and extracellular contents to enter.24 Second is the sodium-potassium pump, which plays an Materials and Methods important role in preserving essential intracellular and extracellular electrolyte distribution.25 Third, cell membranes can also be disrupted as a consePubMed, Medline, Bireme, Scielo and Lilacs quence of severe electrolyte imbalances.25,26 library, besides textbooks, specialized journals, and Muscular injury leads to disruption of the internal internet were searched between June and January cellular structures of muscle cells. Cells with dam2005. The research was made by searching for the aged membranes allow the uncontrolled influx of key words: “rhabdomyolysis OR rhabdomyolysis sodium, chloride, calcium and water down their AND obesity AND surgery OR rhabdomyolysis electrochemical gradients. Large amounts of AND morbid OR obesity”. A total of 39 articles intravascular fluid (up to 12 liters) can leave the cirwere obtained and appraised. culation and become sequestered as edematous fluid in damaged muscle tissue. This fluid shift produces an intravascular hypovolemia and subsequently Published Results hemodynamic instability.27,28 The dramatic decrease in plasma volume leads to vasoconstriction, prePathophysiology of Rhabdomyolysis (RML) renal failure and, eventually, acute intra-renal failure.23 Chloride and calcium also enter the cells, RML is the dissolution of striated muscle of any part causing serum hypocalcemia and calcium deposiof the human body which results in the release of mustion in skeletal muscle and renal tissues.29 cle cell constituents into the extracellular fluid and cirDelivered by Ingenta to: unknown culation (Figure 1). Its consequence is the develop127.0.0.1Among the intracellular components that leak out of damaged skeletal muscle, the most immediately ment of a nonspecific clinical and biochemical syn-Jun 2005 on: Mon, 20 15:26:40 important one is potassium. Because this electrolyte drome, harmful to the human organism.1,15,22,23 is moving from an intracellular area of high concenMyocytes in physiological form show a typical distration into the serum, where a low concentration is tribution of intra- and extracellular ions, which is critinormal, lethal hyperkalemia can develop rapidly cal to the maintenance of normal function. Ions in the with cardiotoxic effects and dysrhythmias.30 body are either predominantly intracellular or extracelPhosphate also leaves the cells, producing hyperlular; none of these have the same distribution.22 phosphatemia. Injured myocytes also leak lactic Three important mechanisms maintain the distincacid and other organic acids, promoting metabolic acidosis and aciduria. Purines released from disintegrating cells are metabolized to uric acid and can High muscle pressure lead to hyperuricemia.22,31 Myoglobin is an oxygen-carrying molecule that Diabetes, hypertension gives muscles their red-brown color. Lysis of as litPeripheral vascular disease tle as 100 g of skeletal muscle results in myoglobinMuscle ischemia uria. Myoglobin is also nephrotoxic in patients with concomitant oliguria and aciduria.22,24 Thromboplastin and tissue plasminogen are Long operative time released from injured muscle tissue, making patients with RML susceptible to disseminated intravascular Rhabomyolysis coagulation, mainly when associated with sepsis.24,25,28,31-33 RML also produces extreme increases in serum levels of creatinine phosphokinase (CPK). Figure 1. Pathogenesis of rhabdomyolysis in bariatric 14 CPK has no toxic effects, and elevated plasma CPK surgery. Obesity Surgery, 15, 2005 875 Tavares de Menezes Ettinger et al levels are simply a marker of increased permeability of muscle membranes. However, high values are pathognomonic for RML, because no other condition will lead to such extreme CPK elevations.34 Prevention of Rhabdomyolysis in Bariatric Surgery Prevention of RML avoids serious outcomes of this important complication (Table 1). Bostanjain et al21 concluded that prevention is enhanced by careful Rhabdomyolysis in Bariatric Surgery padding on the operative table. The same opinion is shared by Mognol et al14 who agree that in morbidly RML in bariatric operations is caused by tissue obese patients, prevention includes adequate padding compression with extended periods of immobilizaat all pressure-points during surgery. Khurana et al9 tion. This leads to muscle ischemia which interferes advise protective padding added around the hips, with oxygen delivery to the cells, thereby limiting shoulders and buttocks (areas adjacent to bone promiproduction of adenosine triphosphate (ATP) and nences) to minimize the surface and deeper pressure, function of sodium-potassium membrane pumps. by distributing pressure over a greater surface area.9 Therefore, serious complications such as hyperIseri et al36 suggest the use of pneumatic beds during kalemia, hypocalcemia, hyperphosphatemia, comsurgery to prevent the occurrence of RML. partment syndrome, disseminated intravascular Hofmann and Stoller37 point out that obese surgicoagulation (DIC), cardiac disorders, acute renal cal patients can position themselves on the surgical failure (ARF) and death may occur. Animal studies table before induction of anesthesia, to the most have demonstrated myonecrosis when an intracomappropriate position, avoiding positions that can partimental pressure of 30 mmHg was applied for 422 increase muscle compression. These authors also 8 hours. Recognized risk factors for the developsuggest the use of two combined surgical tables to ment of postoperative RML are prolonged duration decrease the pressure on the back surface of the of operation, massive obesity, surgical compressive massively obese patient. positioning and endocrine or metabolic disorders Delivered by IngentaWiltshire to: unknown et al38 recommend that special attention be such as diabetes and hypertension. Another cause127.0.0.1 is given to protect injured and uninjured muscle tissue in peripheral vascular disease which is on: a predisposing Mon, 20 Jun 2005 15:26:40 the morbidly obese patient. This can be achieved by factor for compartmental syndrome.35 frequently changing patient position, both intraoperaLong duration of surgery promotes more tissue tively (for operations lasting >2-3 hours) and postopcompression and ischemia. RML has occurred after eratively. Bocca et al39 also assert that preventive operations in non-obese patients when the surgery measures such as good positioning9 and peroperative was >7 hours. Obese patients are at risk during repositioning of the patient can prevent RML. shorter operative procedures (<7 hours). Obesity 1 Bostanjian et al21 emphasize that the duration of increases tissue compression, where the weight is 21 >30% above ideal weight. RML is a complication of various non-physiological positions, eg. the seated, lateral decubitus, prone, exaggerated or high Table 1. Prevention of Rhabdomyolysis in Bariatric Surgery lithotomy, genupectoral, knee-chest or tucked, supine and hyperlordotic positions.36-38 Super-obese Padding pressure areas male patients (BMI >50) with hypertension, diaUse of pneumatic beds during operation betes and peripheral vascular disease are at greater Use of two combined surgical tables risk for RML. These factors are not independent: Optimal position on surgical table super-obese male patients are more likely to be diaLimit surgical time : • Reduce weight before bariatric surgery or perform betic and hypertensive, and bariatric surgery in this surgery in two stages population may be more difficult and likely to be • Avoid early in the learning curve associated with longer duration of operations and Changing patient position intra- and postoperatively consequently more tissue compression. Other Aggressive fluid replacement peri-operatively potential etiologic factors include family history of Early ambulation Discontinue statin therapy muscle disease and the consumption of certain Correct risk factors for RML after surgery (Table 2) drugs, notably anti-cholesterol statins. 876 Obesity Surgery, 15, 2005 Prevention of Rhabdomyolysis gical procedures, if adequate preoperative weight immobilization is greater for very heavy patients. This is not only because the operation takes longer loss can be achieved. but also because other aspects of the operation Cholesterol-lowering agents also promote myolyincluding the placement of central lines or arterial sis. As obese patients usually have elevated choleslines are more likely to be difficult and time-conterol, many are on statins at the time of surgery. This suming. The longer the immobilization, the greater may increase the risk of muscle damage, with the is the RML risk, so one potential new solution proother associated factors – elevated BMI, lengthy posed by Regan et al40 and others41 is to decrease the surgery, peripheral vascular disease, and metabolic longer operative time by dividing the procedure into disorders. Statins are first-line drugs for prevention two stages, doing a gastric sleeve resection initially, and treatment of hypercholesterolemia and atheroand then when the patient has lost considerable sclerotic disease. Although statins are generally weight performing the definitive bypass. Regan’s well-tolerated and have a positive impact on human group40 concluded that laparoscopic sleeve gastrechealth, their myotoxic properties should keep physitomy with second-stage Roux-en-Y gastric bypass cians on alert. Mechanisms of statin-induced is feasible and effective. This two-stage approach is myopathy are still not fully understood. Phenotypic a reasonable alternative for surgical treatment of the characteristics of patients, individual statin properhigh-risk super-super-obese (BMI >60) patient. ties, and metabolic interaction with other drugs are Mognol et al14 state that the gastric bypass in two important factors that may increase risk for statin stages is ideal for the morbidly obese hypertensive myopathy. Thus, when the morbidly obese patient is male with type II diabetes. to undergo a bariatric operation and is on statins, Another way to limit the duration of surgery in he/she should be alerted to stop therapy for a period. high-risk patients is alerting surgeons early in their However, in the study of Bostanjian at al,21 there learning curve not to select patients who fall into this was no difference in RML risk between patients group, or to offer such patients a staged procedure.21 Delivered by Ingenta to:used unknown who cholesterol-lowering agents and those Aggressive fluid replacement after surgery127.0.0.1 is who did not. Prospective studies are necessary to For Iseri etJun 2005 15:26:40 another means of preventing RML.14,23 on: Mon, 20 prove the relation between 3-hydroxy-3-methylglual,36 a high urine output should be instituted with the taryl coenzyme A (HMG-CoA) reductase inhibitors administration of IV fluids and diuretics, before, and RML in bariatric surgery. during and after surgery. Another way to prevent RML is to protect injured and uninjured muscle tissue in the obese patient. This can be achieved by frequently changing the surgical Discussion position and encouraging early ambulation. At the São Rafael hospital, we ask the anesthesiologist to change the position each hour; if the patient is very heavy RML has a variety of etiologies, the most common (super-super-obese), this is done every 30 minutes. ones being alcohol abuse, use of illegal drugs, some A strategy developed by our bariatric research team medicines, and muscle compression. The latter is is an intermitent compression pneumatic bed (Figure the main cause of RML with bariatric operations. 2). The pneumatic bed was designed to promote interBecause of the increase in the number of bariatric 42 mittent compression of the dorsal region of patients operations not just in Brazil, but all over the world, submitted to bariatric surgery or in a long-term hospian increasing interest in RML as a bariatric surgical tal stay, with the purpose of preventing posterior tissue complication has been demonstrated. compression, mainly in buttocks, lumbar region and Reducing the body weight before bariatric surgery shoulders, avoiding ulcers and RML. may decrease the duration of surgery. It can be Other risk factors should be corrected to prevent accomplished by hypocaloric diets, physical activity 41,43 RML after surgery (Table 2). They are hypoalbuand endoscopic intragastric balloon. In our minemia, hyperkalemia or hypophosphatemia, sepexperience, the latter is ideally the best way to persis, CPK peak >6,000 IU/l, systemic arterial hyperform bariatric surgery in super-super obese patients, tension, diabetes, and pre-existing azotemia.14 not submitting them to the risks of two different surObesity Surgery, 15, 2005 877 Tavares de Menezes Ettinger et al References 1. Sauret JM, Marinides G, Want GK. Rhabdomyolysis. Am Fam Physic 2002; 65: 907-12. 2. Silva FML, Silva MMML. A Obesidade na Sociedade Moderna. Journal Brasileiro de Medicina 2004; 87: 38-42. 3. Ilias EJ, Kassab P. Cirurgia da obesidade mórbida. Opinião do Especialista, Diálogo Científico 2004; 1: 9-10. 4. Herron DM. The surgical management of severe obesity. Mt Sinai J Med 2004; 71: 63-71. 5. Mokdad AH, Serdula MK, Dietz WH et al. The spread of the obesity epidemic in the United States, 19911998. JAMA 1999; 282: 1519-22. 6. Alberto C, Junior WR. In: Junior ABG, ed. Cirurgia da Obesidade, 1a ed. São Paulo: Editora Atheneu 2002: 19-23. Figure 2. Intermittent Compression Pneumatic Bed. A: Superior view. B: Obese patient lying on bed. C: Bed with 7. Thirlby RC, Randall J. A Genetic “obesity risk index” for the compressor turned off. D: Bed with the compressor patients with morbid obesity. Obes Surg 2002; 12: 25-9. turned on. The pump inflates alternating units, and after 5 8. Quesenberry CP Jr, Caan B, Jacobson A. Obesity, minutes deflates and inflates the others. health services use, and health care costs among members of a health maintenance organization. Arch Intern Med 1998; 158: 466-72. Delivered by Ingenta unknown 9. to: Khuara RN, Baudendistel TE, Morgan EF et al. 127.0.0.1 Postoperative rhabdomyolysis following laparoscopic Conclusion on: Mon, 20 Jun 2005 15:26:40 gastric bypass in the morbidly obese. Arch Surg 2004; 139: 73-6. Because rhabdomyolysis a major, potentially fatal 10.Rubenstein RB. Laparoscopic adjustable gastric complication of bariatric surgery, the best deterrent is banding at a U.S. center with up to 3-year follow-up. padding all pressure-points during surgery, changing Obes Surg 2002; 12: 380-4. patient position, decreasing longer operative duration 11.Brolin RE, Kenler HA, Gorman JH et al. Long-limb by preoperative weight reduction or staging, alerting gastric bypass in the superobese: A prospective ransurgeons early in their learning curve not to select domized study. Ann Surg 1992; 215: 387-95. patients who fall into the RML risk group, and provid12.Fisher BL, Schauer P. Medical and surgical options in ing aggressive and reasonable fluid replacement. More the treatment of severe obesity. Am J Surg 2002; 184: research is necessary regarding RML prevention. 9S-16S. 13.Steinbrook R. Surgery for severe obesity. N Engl J Med 2004; 350: 1075-9. 14.Mognol P, Vignes S, Chosidow D et al. Rhabdomyolysis after laparoscopic bariatric surgery. Table 2. Risk factors for acute renal failure from rhab14 Obes Surg 2004; 14: 91-4. domyolysis after bariatric surgery 15.Lane R, Phillips M. Rhabdomyolysis. BMJ 2003; 30; Hypoalbuminemia 327 (7413): 115-6. Hyperkalemia or hypophosphatemia 16.Criner JA, Appelt M, Coker C et al. Rhabdomyolysis: Sepsis the hidden killer. Medsurg Nurs 2002; 11: 138-43. CPK peak >6,000 IU/l 17.Sulowicz W, Walatek B, Sydor A et al. Acute renal Hypertension Diabetes failure in patients with rhabdomyolysis. Med Sci Pre-existing azotemia Monitor 2002; 8: 24-7. 878 Obesity Surgery, 15, 2005 Prevention of Rhabdomyolysis Disseminated intravascular coagulation (DIC) and 18.Vanholder R, Sever M, Erek E et al. Rhabdomyolysis. rhabdomyolysis in fulminant varicella infection – J Am Soc Neph 2000; 11: 1553-61. case report and review of the literature. Infection 19.Zager RA. Rhabdomyolysis and myohemoglobinuric 1998; 26: 306-8. acute renal failure. Kidney Int 1996; 49: 314-26. 33.Riggs JE, Schochet SS Jr, Parmar JP. Rhabdomyolysis 20.Torres-Villalobos G, Kimura E, Mosquedo JL et al. with acute renal failure and disseminated intravascuPressure-induced rhabdomyolysis after bariatric surlar coagulation: association with acetaminophen and gery. Obes Surg 2003; 13: 306-13. ethanol. Mil Med 1996; 161: 708-9. 21.Bostanjian D, Anthone GJ, Hamoui N et al. 34.Dayer-Berenson L. Rhabdomyolysis: a comprehenRhabdomyolysis of gluteal muscles leading to renal sive guide. Nephrol Nurs J 1994; 21: 15-8. failure: a potentially fatal complication of surgery in 35.Gorecki PJ, Cottam D, Ger R et al. Lower extremity the morbidly obese. Obes Surg 2003; 13: 302-5 compartment syndrome following a laparoscopic Roux22.Criddle LM. Rhabdomyolysis. Pathophysiology, en-Y gastric bypass. Obes Surg 2002; 12: 289-91. recognition, and management. Crit Care Nurs 2003; C, Senkul T, Reddy PK. Major urologic surgery 36.Iseri 23: 14-22, 24-6, 28 passim; quiz 31-2. and rhabdomyolysis in two obese patients. Int J Urol 23.Collier B, Goreja MA, Duke III BE. Postoperative 2003; 10: 558-60. rhabdomyolysis with bariatric surgery. Obes Surg 37.Hofmann R, Stoller ML. Endoscopic and open stone 2003; 13: 941-3. surgery in morbidly obese patients. J Urol 1992; 148 24.Haskins N. Rhabdomyolysis and acute renal failure in (3 Pt 2): 1108-11. intensive care. Nurs Crit Care 1998; 3: 283-8. 38.Wiltshire JP, Custer T. Lumbar muscle rhabdomyoly25.Slater MS, Mullins RJ. Rhabdomyolysis and myoglosis as a cause of acute renal failure after Roux-en-Y binuric renal failure in trauma and surgical patients: a gastric bypass. Obes Surg 2003; 13: 306-13. review. J Am Coll Surg 1998; 186: 693-716. 39.Bocca G, van Moorselaar JA, Feitz WF et al. 26.Moghtader J, Brady WJ Jr, Bonadio W. Exertional Compartment syndrome, rhabdomyolysis and risk of rhabdomyolysis in an adolescentDelivered athlete. Pediatr by Ingenta to: unknown 127.0.0.1 acute renal failure as complications of the lithotomy Emerg Care 1997; 13: 382-5. position. J Nephrol 2002; 15: 183-5. on: renal Mon,failure 20 Jun 2005 15:26:40 27.Abassi A, Hoffman A, Better O. Acute 40.Regan JP, Inabnet WB, Gagner M et al. Early expericomplicating muscle crush injury. Semin Nephrol ence with two-stage laparoscopic Roux-en-Y gastric 1998; 18: 558-65. bypass as an alternative in the super-super-obese 28.Cheney P. Early management and physiologic patient. Obes Surg 2003; 13: 861-4. changes in crush syndrome. Crit Care Nurs Q 1994; 41.Milone L, Strong V, Gagner M. Laparoscopic sleeve 17: 62-73. gastrectomy is superior to endoscopic intragastric bal29.Russel TA. Acute renal failure related to rhabdomyolloon as a first stage procedure for super-obese patients ysis: pathophysiology, diagnosis and collaborative (BMI ≥50). Obes Surg 2005; 15: 612-7. management. Nephrol Nurs J 2000; 27: 567-77. 42. Buchwald H, Williams SE. Bariatric surgery world30.Gronert GA. Cardiac arrest after succinylcholine: wide 2003. Obes Surg 2004; 14: 1157-64. mortality greater with rhabdomyolysis than receptor 43.Busetto L, Segato G, De Luca M et al. Preoperative upregulation. Anesthes 2001; 94: 523-9. weight loss by intragastric balloon in super-obese 31.Curry SC, Chang D, Connor D. Drug- and toxinpatients treated with laparoscopic gastric banding. induced rhabdomyolysis. Ann Emerg Med 1989; 18: Obes Surg 2004; 14: 671-6. 1068-84. 32.Hollenstein U, Thalhammer F, Burgmann H. (Received April 28, 2005; accepted May 27, 2005) Obesity Surgery, 15, 2005 879
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